7. Diseases Of The Gallbladder And Bile Ducts Flashcards
Chemical that stimulates gallbladder contraction.
CCK
This chemical mediates the relaxation of the sphincter of Oddi.
CCK
What does relaxation of the sphincter of Oddi allow?
Biliary and pancreatic secretions to enter the duodenum.
Composition of micelles of bile salts.
Cholesterol
Phospholipids
Main component of bile pigments
Bilirubin
Type of gallstone that is mostly calcium bilirubinate (black and brown).
Pigment (associated w/chronic infection or disease states w/ chronic hemolysis)
________secrete bile acids.
Hepatocytes
The 5 F’s: Risk factors for Cholelithisasis
Fat (BMI >30) Female Fertile Forty >40 Fair *Familial
Composition of biliary sludge
Cholesterol crystals
Calcium bilirubinate
Mucin gels
Presence of sludge means: (two things)
1) normal balance deranged
2) Nucleation
Stone and sludge in the gallbladder can cause these 3 main issues: (there are more)
1) Cholelithiasis-stones present, no sx
2) Acute cholecystitis- inflammation
3) Chronic cholecystitis-“great imitator”
This produces increased intraluminal pressure and distension of the gallbladder viscous that CANNOT be relieved by repeated biliary contractions.
Obstruction of the cystic duct OR CBD by stone
A patient presents with SEVERE pain in RUQ that radiates to right shoulder. Consider:
Biliary colic
Big factor that should make you suspicious of acute cholecystitis?
Long duration of pain (>5 hrs)
Precipitating factors for biliary colic:
Fatty meal
Meal after fasting
Any meals
When does biliary colic usually occur?
Nocturnal, w/in a few hrs of retiring
Arrest of inspiration on palpation of gallbladder.
Murphy’s sign
First step in evaluation for gallbladder disease.
Ultrasound
If ultrasound of gallbladder is inconclusive and patient is NOT acutely ill, what would be your next step?
HIDA scan
- fast 4 hrs prior
- evaluated bile-excreting function of liver and gallbladder EF
If pt. is acutely ill with gallstones, what else would you test for?
CBC (leukocytosis?)
Hepatic panel
_________% of people with asymptomatic gallstones will remain asymptomatic-25yrs.
60-80
Gallbladder polyps occur in _____% of pop.
5
A patient comes in for an ultrasound (not gallbladder related) and you find an 11mm polyp. She is 59 yrs old. What should you do?
Cholestystectomy
A 49 yr old patient comes in for a routine RUQ ultrasound (not sure what for), she has no pain, fever etc. You find a 9mm polyp. What should you do?
Monitor
A patient comes with SUDDEN RUQ pain, 101 fever, and leukocytosis. Consider:
Acute cholecystitis
3 sources of inflammation of the gallbladder wall in acute cholecystitis.
1) Mechanical inflammation (distention)
2) Chemical inflammation (local tissue factors)
3) Bacterial inflammation (E. Coli, Strep etc)
Acute inflammation of the gallbladder wall following obstruction of the cystic duct by a stone.
Acute cholecystitis
Steps for acute cholecystitis work up.
1) Ultrasound!
2) Hepatic panel
3) CBC
*gen. Surg
A pt. Comes in with no current pain, but said they recently had a “EXTREME bout of pain in the RUQ” a few days ago in the middle of the night. Next steps?
Ultrasound>Gen Surgery
*tell them to go to ER next time this happens
What kind of drugs can induce sphincter of Oddi spasms?
Morphine-based
If a patient with acute cholecystitis is in severe pain, high fever and leukocytes, what would you do?
1) Medically stabilize.
* NPO, IV FLUIDS, Fix electrolytes, NSAIDS, IV Antibiotics
2) Lap Cholecystitis
Alternative to lap chol for extremely ill pt’s.
Percutaneous cholecystostomy tube (* gen surg decides)
What would you use to evaluate for common bile duct stones during a lap chol?
Intraoperative cholangiogram (IOC)
During a lap chol, what would you use to retrieve small CBD stones?
ERCP
A post-cholecystectomy complains of severe diarrhea, what could give them?
Bile acid sequestration like Cholestyramine (Questran)
A patient presents with severe abdominal pain, jaundice, and a high fever with chills. What is this triad of sx’s called and what might be happening?
Charcot’s triad
Bile Duct Leak
How would you evaluate a build duct leak?
ERCP
*Stent CBD
When gallstones pass into the CBD:
Choledocholithiasis
When bile ducts are partially to completely obstructed and bacteria begins to climb the biliary tree into the liver:
CHOLANGITIS
Type of cholangitis in which pus is under pressure in a completely obstructed ductal system.
Suppurative cholangitis
*Mortality rate approaches 100%
Tx for cholangitis
Empiric antibiotics (IV) ERCP or surgical drainage
What drug would you use to dissolve cholesterol type stones?
Ursodeoxycholic acid (UCDA)
